Promoting self-determination of persons with severe or profound intellectual disabilities: a systematic review and meta-analysis.

People with severe or profound intellectual disabilities (IDs) are believed to experience low levels of self-determination, which negatively affects their quality of life. This systematic review describes existing interventions aimed to support self-determination or components thereof and synthesises evidence on the interventions' effects. Eight databases were searched, turning in 76 articles for the final inclusion. The studies included 631 people with severe or profound IDs of whom 81% had multiple disabilities. The studies had quantitative (k = 63), qualitative (k = 7) and mixed study designs (k = 6). Sample sizes ranged from 1 to 95 and a study quality index ranged from 40% to 100%. While many studies included several self-determination components and intervention elements, overall, 53 studies focused on the self-determination components choice making, independence and problem solving. Other studies included increased assistance (k = 14); engagement in meaningful activities and relationships (k = 10); community and societal participation (k = 5); supporting the basic psychological needs autonomy, competence and relatedness (k = 4); individuality and dignity (k = 3); supportive decision-making (k = 2); self-advocacy (k = 2); and motivation (k = 1). Intervention elements included technology (k = 33); multiple-component training packages, goal setting, empowerment tactics and applied behaviour principles (k = 17); training of caretakers (k = 17); changes in policies and living arrangements (k = 9); supporter responsiveness (k = 1); drama therapy and storytelling (k = 1); electrical wheelchair training (k = 1); joint painting procedure (k = 1); youth advocacy project (k = 1); and multiliteracies training (k = 1). Reflecting the heterogeneity of the field, only four studies tested a similar intervention for this population and were eligible for the meta-analysis, which combined showed a small effect size of 2.69. Further research is needed to explore relationships between individuals with severe or profound IDs and their relatives and health care professionals and create supportive environments that meet their basic psychological needs.

Impact of the Care and Coercion Act on recorded involuntary care in intellectual disability care: a time-series analysis.

BACKGROUND: On 1 January 2020, the Care and Coercion Act came into effect in the Netherlands, subjecting involuntary care to more strict regulations and monitoring. This study tested changes in recordings of involuntary care during the transitional year of 2020 and after full implementation in 2021, which coincided with the first severe test of the new regulations, when COVID-19 lockdown measures were taken on 16 March 2020. METHODS: Data consisted of weekly counts of involuntary care from 1 January 2017 to 31 December 2021, taken from the care data of more than 3000 clients with intellectual disabilities and challenging behaviour of 's Heeren Loo, a large long-term care organisation in the Netherlands. An interrupted time series design was used to compare the period under the former law with the period under the new law and to the period during and after implementation, taking into account the impact of the COVID-19 lockdown measures on recordings of involuntary care. RESULTS: Under the new act in Week 1 of 2020, a statistically significant drop occurred in involuntary care counts, after which these counts gradually decreased. The start of 2021, the year in which the act was fully implemented, showed an initial increase in counts of involuntary care, followed by a decrease (all Ps < .001). The introduction of the COVID-19 lockdown measures did not statistically affect the weekly counts of involuntary care. CONCLUSIONS: The decrease in registered involuntary care after the Care and Coercion Act came into effect is a first indication of the efficacy of this new law that requires careful multidisciplinary consultations around the right of clients to respect their self-determination. Follow-up research should examine whether the impact of the new law aligns with clients' experiences of self-determination.

Reproductive health of women with intellectual disability: antenatal care, pregnancies and outcomes in the Dutch population.

BACKGROUND: Research in a handful of countries found that women with intellectual disability (ID) faced barriers and risks regarding antenatal care and reproductive health. This study tested disparities between women in the Netherlands with and without ID in antenatal care, pregnancy rates and pregnancy outcomes. METHODS: Secondary analyses on the large representative panel of primary health patients in the Netherlands by the Netherlands Institute for Health Services Research (NIVEL) compared women in their reproductive age (18-49 years) with (n = 2397) and without (n = 228 608) indicators of ID. Bias due to underreporting and under-identification was reduced by linkage with an index of ID for the total Dutch population from Statistical Netherlands. RESULTS: Women with ID were more likely to receive contraceptive care [95% confidence interval (CI) for odds ratio (OR) = 1.37-1.61] and became somewhat more often pregnant (95% CI OR = 1.06-2.30) than women from the general population, adjusting for age difference and follow-up time. No statistical differences were found in medical complications during pregnancy, delivery and immediately after birth, but women with indicators of ID had a higher risk of losing their pregnancy, including through induced abortion (95% CI OR = 1.26-1.99). CONCLUSIONS: Women with ID have specific needs around contraceptive care and risks around their pregnancy that may require more awareness among practitioners and better understanding of the processes of care and decision-making.

Evaluating the self-determination continuum towards seeking support among people with mild to borderline intellectual disabilities.

BACKGROUND: Providing professional support for people with mild to borderline intellectual disabilities (IDs) is supposed to support their autonomous participation in society and, in turn, enhance their well-being and quality of life. However, the motivation for seeking support may differ for people with mild to borderline IDs, varying in the extent to which the person's autonomy is self-determined. The present study tested the association between different types of motivation for seeking support and well-being. METHOD: Adults with mild to borderline IDs (N = 154) participated in a cross-sectional survey. Researchers administered the Self-Regulation Questionnaire - Support - II (SRQ-S-II) and a life satisfaction questionnaire. To determine the test-retest reliability of the SRQ-S-II, 30 participants completed a follow-up questionnaire. RESULTS: The motivations cited by people with mild to borderline IDs for seeking support ranged from amotivation to intrinsic motivation. Multiple regression analysis indicated that the model explained 56.6% of the variance, with intrinsic motivation (ß = 0.361, P < 0.001) and identified motivation (ß = 0.381, P = 0.001) proving to be significant predictors in terms of explaining the highest percentage of variance in well-being. Amotivation (ß = -0.247, P = 0.004) and introjected motivation (ß = -0.145, P = 0.03) contributed significantly to the model with negative beta coefficients. Finally, reliability measures (Cronbach's alphas, MacDonald's omegas and test-retest reliabilities) indicated that all types of motivation for seeking support could be reliably assessed. CONCLUSIONS: The results of the present study showed that people with mild to borderline IDs displayed the full range of types of motivations for seeking support and, moreover, that it was associated with well-being. Studying these motivational states, and increasing our awareness of what motivates this population to seek support, can aid the design of more effective support that respects self-determination and well-being. The SRQ-S-II is thus an important instrument for understanding the role of support in promoting well-being.

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

BACKGROUND: The lockdown-measures in response to COVID-19 taken by long-term care organisations might have impacted problem behaviour and behavioural functioning of people with intellectual disability. This study tested changes in reported incidents, in particular regarding aggression, unexplained absence and, for contrast, medication errors. METHODS: Metadata on weekly incident and near-incident reports from 2016 to June 2020 involving over 14 000 clients with mild to serious intellectual disability of 's Heeren Loo, a long-term care organisation for people with intellectual disability, were subjected to interrupted time series analysis, comparing the COVID-19 with the pre-COVID-19 period. RESULTS: The imposition of lockdown-measures coincided with a significant drop in incidents (total, P < .001; aggression, P = .008; unexplained absences, P = .008; and medication errors, P < .001). Incidents in total (P = .001) and with aggression (P < .001) then climbed from this initial low level, while medication errors remained stably low (P = .94). CONCLUSION: The rise in incidents involving aggression, against the background of generally lowered reporting, underlines the need for pandemic control measures that are suitable for people with intellectual disability in long-term care.

Accidental and Ambiguous Situations Reveal Specific Social Information Processing Biases and Deficits in Adolescents with Low Intellectual Level and Clinical Levels of Externalizing Behavior.

Addressing aggression in youth requires understanding of the range of social problem situations that may lead to biased social information processing (SIP). The present study investigated situation-specificity of SIP and analyzed whether SIP deficits and biases are found in ambiguous as well as clearly accidental situations in adolescents with clinical levels of externalizing behavior or with low intellectual level, congruent with mild intellectual disability. Adolescents (N = 220, Mage = 15.21) completed a SIP test on a mobile app with six videos with ambiguous, hostile, and accidental social problems. Caretakers, teachers, and adolescents themselves reported on youth externalizing behavior problems. In accidental situations specifically, adolescents with low IQ scores more often attributed purposeful intent to perpetrators than peers with borderline or average IQ scores. In accidental situations, adolescents with clinical levels of externalizing behavior generated and selected more aggressive responses than nonclinical adolescents, regardless of their cognitive level. In line with previous literature, the ambiguous situations also brought out SIP differences between IQ groups. These results suggest that not only ambiguous situations should be considered informative for understanding SIP biases, but situations in which adolescents are clearly accidentally disadvantaged bring out SIP biases as well, that may lead to conflicts with others.

Effects of video-feedback intervention on harmonious parent-child interaction and sensitive discipline of parents with intellectual disabilities: A randomized controlled trial.

BACKGROUND: This study tested whether video-feedback intervention based on attachment and coercion theory increased harmonious parent-child interaction and sensitive discipline of parents with mild intellectual disabilities or borderline intellectual functioning. METHODS: Observer ratings of video-recorded structured interaction tasks at home formed pretest, post-test, and 3-month follow-up outcome data in a randomized controlled trial with 85 families. Repeated measures analyses of variance and covariance were conducted to test for the intervention effect and possible moderation by IQ and adaptive functioning. RESULTS: The intervention effect on harmonious parent-child interaction was conditional on parental social adaptive behaviour at pretest, with lower adaptive functioning associated with stronger intervention benefit at post-test and follow-up compared to care as usual. Intervention effects were not conditional on parental IQ. Intervention effects for sensitive discipline were not found. CONCLUSION: Although the video-feedback intervention did not affect observed parenting for the average parent, it may benefit interaction between children and parents with lower parental adaptive functioning.

Self-concept in institutionalized children with disturbed attachment: The mediating role of exploratory behaviours.

BACKGROUND: Self-concept is seen as both an outcome of sociocognitive and emotional development, and a factor in social and mental health outcomes. Although the contribution of attachment experiences to self-concept has been limited to quality of primary attachment relationships, little is known of the effects of disturbed attachment on self-concept in institutionalized children. Thus, the current study examined associations between disturbed attachment behaviours in institutionalized children and self-concept, testing limited exploration as an explanatory factor. METHODS: Thirty-three institutionalized children, aged 4-12, participated in a multimethod and multi-informant assessment of disturbed attachment behaviours (i.e., Disturbances of Attachment Interview and Behavioral Signs of Disturbed Attachment in Young Children), self-concept (i.e., Pictorial Scale of Perceived Competence and Social Acceptance for Young Children), and exploratory behaviours (i.e., Student Exploratory Behaviours Observation Scale). Analyses were conducted using bootstrapping techniques. RESULTS: Global self-concept converged with teacher-rated children's self-concept, except for physical competence domain. Disturbed attachment behaviours were identified in 62.5% of the children, and this was associated with lower levels of exploration and lower scores on self-concept, compared with children without disturbed attachment behaviours. Furthermore, exploratory behaviours mediated the effects of disturbed attachment behaviours on self-concept. CONCLUSIONS: Institution-reared children with disturbed attachment behaviours were likely to have a negative perception of self and one's own competences. Limited exploratory behaviours explained this linkage. Targeting disordered attachment in children reared in institutions and their caregivers should become a high priority as a means for preventing socioemotional development issues.

From prenatal anxiety to parenting stress: a longitudinal study.

The objective of this study was to explore how maternal mood during pregnancy, i.e., general anxiety, pregnancy-specific anxiety, and depression predicted parenting stress 3 months after giving birth, thereby shaping the child's early postnatal environmental circumstances. To this end, data were used from 1073 women participating in the Dutch longitudinal cohort Generations2, which studies first-time pregnant mothers during pregnancy and across the transition to parenthood. Women filled out the State Trait Anxiety Inventory (STAI), Pregnancy-Related Anxiety Questionnaire-revised (PRAQ-R), and Beck Depression Index (BDI) three times during pregnancy: at 12, 22, and 32 weeks gestational age. Three months postpartum, a parenting stress questionnaire was filled out yielding seven different parenting constructs. Latent scores were computed for each of the repeatedly measured maternal mood variables with Mplus and parenting stress constructs were simultaneously regressed on these latent scores. Results showed that trait anxiety and pregnancy-specific anxiety were uniquely related to almost all parenting stress constructs, taking depression into account. Early prevention and intervention to reduce maternal anxiety in pregnancy could hold the key for a more advantageous trajectory of early postnatal parenting.

Distinguishing subtypes of extrinsic motivation among people with mild to borderline intellectual disability.

BACKGROUND: According to self-determination theory, motivation is ordered in types, including amotivation, extrinsic motivation and intrinsic motivation. Self-determination theory defines four subtypes of extrinsic motivation: external motivation, introjected motivation, identified motivation and integrated motivation. Although it has been argued theoretically that the different types of motivation are universally applicable, Reid et al. () proposed a dichotomy of broad subtypes of extrinsic motivation for people with intellectual disability (ID) due to their cognitive limitations. The current study challenges this proposal by testing whether the four subtypes of extrinsic motivation can be differentiated among people with ID as well. METHOD: The subtypes of extrinsic motivation were measured using two adapted versions of the Self-Regulation Questionnaire, one regarding exercise and one regarding support. In total, 186 adults with mild to borderline ID participated in the study. RESULTS: Results supported the distinction between the four subtypes of extrinsic motivation regarding both exercise and support. In addition, the correlation coefficients supported a quasi-simplex pattern of correlations among the subtypes, indicating that adjacent subtypes were more closely related than non-adjacent subtypes. Moreover, the study showed sufficient Cronbach's alphas and test-retest reliabilities for early stage research. CONCLUSIONS: Overall, the results of the current study provide initial evidence for the universality of the four subtypes of extrinsic motivation across populations with and without ID.

Attachment relationships of preschool-aged children of mothers with HIV and HIV-related psychosis.

Children from mothers with HIV-related psychosis are frequently raised in challenging contexts, yet the extent to which these children grow up in insecure or disordered attachment relationships is unknown. Using the Strange Situation Procedure the distribution of attachment relationships of children from mothers with HIV and psychosis (n = 45) was compared with children from mothers with HIV without psychosis (n = 41). No significant differences in the distributions were found between the two groups and attachment was not associated with specific psychotic symptomatology. Security of attachment was associated with more people providing the mother with emotional support, but only in the psychosis group. Disordered attachment (24%) was more often found in the total sample than in studies with other normal and high risk populations. Recommendations were made for future research about factors facilitating resilience in the children and on interventions increasing emotional support for affected mothers.

Inhibited attachment behaviour and disinhibited social engagement behaviour as relevant concepts in referred home reared children.

BACKGROUND: Disorders of attachment and social engagement have mainly been studied in children, reared in institutions and foster care. There are few studies amongst home reared children living with biological parents. The aim of this study was to test the clinical significance of inhibited attachment behaviour and disinhibited social engagement behaviour in young home reared children, referred for treatment of emotional and behavioural problems, compared with young children in treatment foster care. METHODS: The Disturbances of Attachment Interview, Maltreatment Classification System, the Child Behaviour Checklist and Parenting Stress Index were used in 141 referred home reared children and 59 referred foster children, aged 2.0-7.9 years (M = 4.7, SE = 1.3), 71% boys. RESULTS: Inhibited attachment behaviour was less prevalent in the referred home reared group (9%) than in the foster care group (27%). Disinhibited social engagement behaviour was found in 42% of the home reared group, similar to the foster care group. Inhibited attachment behaviour and disinhibited social engagement behaviour were not associated with child maltreatment. More inhibited attachment behaviour was associated with clinical levels of child internalizing and externalizing behaviour in the home reared group, not in the foster care group. In both groups, more disinhibited social engagement behaviour was associated with clinical levels of externalizing behaviour and with more parenting stress. CONCLUSIONS: Even without evident links to maltreatment, results of this study suggest clinical significance of inhibited attachment behaviour and disinhibited social engagement behaviour in young home reared children referred for treatment of emotional and behavioural problems.

Pretreatment for substance-abusing people with intellectual disabilities: intervening on autonomous motivation for treatment entry.

BACKGROUND: Despite a lack of consensus regarding prevalence rates of substance abuse, people with intellectual disabilities (ID) on average use substances slightly less often than their non-disabled peers. However, their use of substances is more often problematic. Avoidance of treatment is a crucial problem among substance-abusing people with ID. This study tested a motivational intervention to facilitate autonomous motivation (i.e. wanting to change substance abuse because of a sense of free choice and volition) for engaging with a subsequent addiction treatment. METHOD: A multiple-case experimental design (N = 6) was conducted to measure day-to-day motivation to change substance abuse among individuals with mild ID (N = 3) and borderline level of intellectual functioning (N = 3) in the Netherlands. The participants (five men, one woman) lived in the community (except one, he lived in a residential facility) and abused cannabis, alcohol or hashish. During the intervention phase, the 10-session treatment programme 'Beat the kick' was delivered by an experienced psychologist, based on motivational interviewing techniques adapted for people with mild to borderline ID. Participants completed an adaptive self-reported inventory based on self-determination theory (SDT) two to three times a week during baseline, intervention and 1-month follow-up. RESULTS: The results of five of the six participants (one dropped out) showed that the type of motivation changed from more controlled types of motivation (i.e. external motivation and introjected motivation) at baseline to more autonomous types of motivation after completion of the intervention. In addition, the participants reported a significant increase in overall need satisfaction and autonomy satisfaction and a significant decrease of overall need frustration. CONCLUSIONS: The implementation of SDT and motivational interviewing principles in the treatment programme 'Beat the kick' reliably changed the type of motivation. In addition, the experimental effects provide initial proof of the use and applicability of SDT among people with ID.

Moderators of the efficacy of a psychosocial group intervention for children with chronic illness and their parents: what works for whom?

OBJECTIVE: To investigate psychosocial characteristics of children and parents as predictors and moderators of the effect of a group intervention for children with chronic illness and their parents. METHODS: Data from a randomized controlled trial were used, including 194 children (8-18 years) who were assigned to a child-only intervention, a parent-child intervention, or a wait-list control group. Longitudinal multilevel regression analyses were used to test effects on change in parent and child reported internalizing and externalizing behavior problems. RESULTS: For children with a more disengaged coping style or lower self-worth and for children who experienced a more secure parent-child relationship, the parent-child intervention was more effective than the child-only intervention in reducing behavior problems. CONCLUSIONS: Children who are more "at risk" appear to gain more from participating in an intervention, especially if their parents are involved as well. However, the benefit of parents' involvement may depend on the quality of the parent-child relationship.

Psychiatric diagnostic screening of social maladaptive behaviour in children with mild intellectual disability: differentiating disordered attachment and pervasive developmental disorder behaviour.

BACKGROUND: Children with intellectual disability (ID) are at risk for maladaptive development of social relatedness. Controversy exists whether Pervasive Developmental Disorder (PDD) takes precedence over disordered attachment for describing maladaptive social behaviour. The aim of this study was to assess the prevalence of disordered attachment symptoms in children with ID referred for mental health diagnosis, and to study the potential diagnostic overlap between symptoms of disordered attachment and PDD symptoms. METHOD: Children (n = 102) in the age of 5-11 with IDs (borderline or mild; IQ 50-85) referred for psychiatric consultation were recruited. Parents were administered a screening interview for disturbances of attachment and teachers were administered a screening questionnaire for PDD. RESULTS: Behavioural symptoms of disordered attachment were reported for 42%* of the children, with 16%* showing symptoms of inhibited and 37%* showing symptoms of disinhibited attachment disorder. In 11% both types of symptoms were noted. Attachment disorder symptoms were not significantly associated with gender, ethnic background or age. Positive screening for PDD occurred for 27%. Positive screening for PDD was not significantly associated with symptoms of attachment disorder. CONCLUSIONS: Among children with ID referred for psychiatric consultation, Reactive Attachment Disorder (RAD) and PDD symptoms were both highly prevalent. RAD and PDD symptoms appear as distinct, but sometimes comorbid, forms of aberrant social relatedness.

Parenting stress and child behaviour problems among parents with intellectual disabilities: the buffering role of resources.

BACKGROUND: Parents with intellectual disabilities (ID) are at risk for high levels of parenting stress. The present study evaluated resources, including parental adaptive functioning, financial resources and access to a support network, as moderators of the association between child behaviour problems and parenting stress. METHOD: A total of 134 parents with ID and their children (ages 1-7 years) were recruited from 10 Dutch care organisations. Questionnaires were administered to the parents to obtain information on parenting stress in the parent and child domain, financial resources and their support network. Teachers and care workers reported on child behaviour problems and parental adaptive functioning, respectively. RESULTS: Parents experienced more stress with regard to their children than towards their own functioning and situation. Parenting stress was less in parents who were not experiencing financial hardship. Child behaviour problems were associated with high child-related parenting stress, not parent-related parenting stress. Large support networks decreased the association between child behaviour problems and child-related parenting stress. Financial resources did not significantly moderate the association. CONCLUSIONS: Parenting stress among parents with ID is focused on problems with the child, especially when little social support is available.

The interrelationship between pregnancy-specific anxiety and general anxiety across pregnancy: a longitudinal study.

BACKGROUND: High levels of prenatal maternal anxiety - either pregnancy-specific anxiety or general anxiety - may have detrimental effects on both the mother and her child. It is currently unknown how these two different expressions of anxiety influence each other over time during pregnancy. AIMS: This study aimed to describe the relationship between state, trait and pregnancy-specific anxiety levels across pregnancy. METHODS: Longitudinal data from three data-waves of a large-scaled sample of nulliparous normal risk pregnant women were used to display associations over time by means of autoregressive and cross-lagged panel models. RESULTS: Cross-lagged, cross-time pathways from pregnancy-specific anxiety to state as well as trait anxiety were positively significant, while vice versa the most consistent links were found from trait anxiety to pregnancy-specific anxiety. CONCLUSIONS: We conclude that pregnancy-specific anxiety and general anxiety appear to influence each other over time, resulting in heightened anxiety for some soon-to-be mothers.

Does format matter for comprehension of a facial affective scale and a numeric scale for pain by adults with Down syndrome?

People with intellectual disabilities are at high risk for pain and have communication difficulties. Facial and numeric scales for self-report may aid pain identification. It was examined whether the comprehension of a facial affective scale and a numeric scale for pain in adults with Down syndrome (DS) varies with presentation format. Adults with DS were included (N=106, mild to severe ID, mean age 37 years), both with (N=57) and without (N=49) physical conditions that may cause pain or discomfort. The Facial Affect Scale (FAS) and a numeric rating scale (NRS) were compared. One subgroup of participants (N=50) had to choose the two items within each format to indicate 'least pain' and 'most pain'. The other subgroup of participants (N=56) had to order three faces of the FAS from 'least pain' to 'most pain', and to answer questions about the magnitude of numbers for the NRS. Comprehension percentages were compared between two subgroups. More participants understood the FAS than the NRS, irrespective of the presentation format. The comprehension percentage for the FAS did not differ between the least-most extremities format and the ordering/magnitude format. In contrast, comprehension percentages for the NRS differed significantly between the least-most extremities format (61%) and the ordering/magnitude format (32%). The inclusion of ordering and magnitude in a presentation format is essential to assess thorough comprehension of facial and numeric scales for self-reported pain. The use of this format does not influence the number of adults with DS who pass the comprehension test for the FAS, but reduces the number of adults with DS who pass the comprehension test for the NRS.

Effects of video-feedback interaction training for professional caregivers of children and adults with visual and intellectual disabilities.

BACKGROUND: Individuals in group homes may experience poor quality of social interaction with their professional caregivers, limiting their quality of life. The video-based Contact programme may help caregivers to improve their interaction with clients. METHOD: Seventy-two caregivers of 12 individuals with visual and intellectual disabilities received a training programme and four individual video-feedback sessions. Quality of interaction was independently measured in an AB-design across subjects with two baseline and three intervention observations, using a time sampling coding system for interactive behaviour as well as a rating for affective mutuality. RESULTS: From baseline to intervention, significant increases were found for the frequency with which caregivers confirmed the signals of clients, for the proportion of initiatives taken by clients that were responded to by the caregivers, and the affective mutuality as a quality of the interaction. No significant increase in client responsiveness was observed. Caregivers evaluated the intervention as useful and feasible. CONCLUSIONS: The start of the Contact programme coincided with improved quality of interaction between professional caregivers and clients with visual and intellectual disabilities in group homes. Further research is necessary regarding the generalisability, long-term effects and effects on quality of life.

'People who need people': attachment and professional caregiving.

From the perspective of attachment theory, this paper discusses individual differences in the quality of caregiving by direct-care staff for persons with intellectual disabilities. Theoretical arguments and findings from related literature are cited to support the probable role of professionals' own attachment experiences and their mental representations thereof. Case examples are drawn from a study on video-based interaction guidance for direct-care staff in group homes for persons with multiple, serious disabilities. These examples illustrate how interventions may avoid attachment-related defences against changing the quality and affective mutuality of personal contact with clients. However, the possibility is discussed that in parallel processes, quality management systems and institutional culture may selectively reinforce care patterns associated with insecure, dismissing attachment, while failing to reward the positive contribution that sensitive, affectively attuned caregiving makes to wellbeing of persons with disabilities.